Qualitative analysis of the perceptions of rural communities about the use of awareness‐raising videos in nutrition and health programs in Benin

Abstract This cross‐sectional study aims at analyzing the perceptions of mothers, community leaders, and nutrition/health care workers (NHCWs) about using videos in nutrition and health programs compared to posters. In total, we recruited 42 mothers, 39 community leaders, and 30 NHCWs from villages and local organizations in two rural districts in South Benin, Bopa, and Houéyogbé. Learning sessions on Dietary diversity and Hygiene and deworming were organized using posters and videos. Participants' opinions on pros and cons of videos and posters were collected using individual semi‐structured interviews with NHCWs and focus group discussions with mothers and community leaders, then analyzed thematically. Results showed that videos were perceived as more adapted to rural communities than posters because they were in local languages, self‐explanatory, appealing, and captivating. Videos also enabled the dissemination of standardized messages. Globally, participants better‐understood messages from videos than from posters, especially when dealing with dynamic processes. However, the speed of video sequences allowed limited time for self‐reflection and assimilation of certain messages. The absence of electricity and lack of equipment to play videos in villages are also major constraints on the use of videos in such settings. While videos are innovant communication tools that should be promoted to improve motivation and compliance in learnings, they should be preferably used as complements to traditional posters for optimized assimilation of messages.

ence but are particularly useful and effective with low-instruction individuals or populations (Morley, 2009;Sobel et al., 2009;Wlodkowski, 2008). Despite this potential, learning videos are scarcely used in nutrition and health programs in low-income countries. Considering the case of Benin, a West African country, Bentley et al. (2014) documented one experience with the use of videos in the field of agriculture. They showed that videos facilitated the adoption of rice farming or new agricultural technologies; some farmers also visited extension agencies to get rice seeds and information. The authors highlighted that farmers remembered the content of the videos 5 years afterward. Regarding the nutrition area, the government recommends the promotion of videos during nutrition sensitization sessions at the national level (CAN, 2017). Recently our research team (Bodjrènou, 2021;Bodjrenou et al., 2020) conducted a study to assess the actual effectiveness of learning videos compared to more conventional communication tools -posters and flyers -in improving complementary feeding practices in a food-insecure area of Southern Benin where these practices were shown to be suboptimal INSAE & PAM, 2017;Mitchodigni, Amoussa Hounkpatin, Ntandou-Bouzitou, Avohou, et al., 2017;.
Results showed that videos did not perform better than traditional tools in improving young children's dietary diversity and meal frequency (Bodjrenou et al., 2020); however, videos were associated with improved knowledge on exclusive breastfeeding as well as with improved practices regarding breastfeeding on demand and increasing breastfeeding frequency during child's illness (Bodjrènou, 2021).
In order to better explain these mixed findings, and to investigate the operationalization of learning videos in an African rural context, we did set up a qualitative survey with mothers, community leaders, and nutrition/health care workers (NHCWs) in the same two districts. Our objectives were to (i) assess how widely videos are used as communication tools in nutrition and health sensitization sessions in this area, and (ii) analyze users' perceptions of the videos, particularly perceptions of people working in the fields of nutrition and health at the community level as well as beneficiaries. Our hypothesis is that videos used in nutrition and health programs are perceived by mothers, community leaders, and living in Bopa and Houéyogbé, two rural districts of southern Benin, as more efficient than posters.

| Study area
This study was conducted in two rural districts located in the department of Mono in Southern Benin, namely Bopa and Houéyogbé, where complementary feeding practices of young children were inadequate (Mitchodigni, Amoussa Hounkpatin, Ntandou-Bouzitou, Avohou, et al., 2017; and where a high percentage of households experienced food insecurity (41% in Bopa and 34% in Houéyogbé), as compared to the national rate (10%) (INSAE & PAM, 2017). In 2015-2016, a community nutrition and health sensitization program using videos or posters was implemented in the area for a period of 6 months to improve young children's feeding practices and nutritional status (Bodjrenou et al., 2020). The present study took place in the exact same districts. However, we excluded the villages that had directly benefited from this program in the past, as we wanted to hear from people who had not previously been exposed to these tools. From the list of the remaining villages, we randomly selected two villages per district, namely Dado and Tanvé in the district of Bopa, and Hounvi-Atchago and Salahoué in the district of Houéyogbé.

| Study population and selection of participants
We conducted a cross-sectional survey combining qualitative and quantitative approaches, which targeted mothers of children under 2 years old, community leaders at the village level and nutrition and health care workers (NHCWs) at the district level. NHCWs were defined as any person or professional working as an educator in an action or intervention for health, food, or nutrition. We first created an inventory of all institutions and structures intervening in the field of nutrition and health in each of the two districts by consulting the administrative registers and maps of the institutions operating at the district level and by discussing with the administrative authorities.
Thirty institutions and structures were identified, including social promotion centers, health centers, NGOs, and interventional projects in nutrition. From each structure, one person actively involved in community activities was selected to participate in the study (n = 30). In parallel, we used purposive sampling to select participants at the village level. The inclusion criteria for mothers were: (i) having a child under 2 years old, and; (ii) having lived in the village for at least 2 years. A total of 42 mothers were selected with the assistance of village authorities and were deliberately chosen from diverse sociocultural backgrounds (ethnicity, religion, etc.). Community leaders were selected from each village as follows: the village chief, two of the chief's advisors and at least six other influential people or village leaders (when possible, men and women were equally represented).
A total of 39 leaders were selected from all four villages.

| Data collection
At the district level, we conducted semi-structured interviews in French with NHCWs, using interview guides that included both closed-and open-ended questions. Interviewees were asked to make an inventory of the tools their institutions used during nutrition and health sensitization sessions. Next, we gathered their opinions on the relevance of videos in learning sessions in the Bopa and Houéyogbé communities. We also simulated learning sessions on two different topics, using either posters or videos, then investi-

| Data processing and analysis
A double entry of quantitative data was carried out and validated using SPSS 22.0 software. Descriptive analyses (frequencies and means) F I G U R E 1 Overall scheme of the study in villages. This figure presents the overall scheme of the study in the two districts. It presents the logic of the investigation including, for each district: the selected villages, the order of presentation of the topics, and the number of participants in focus group discussions with mothers in one hand and with community leader on the other hand. FGD, Focus Group Discussion. were carried out to determine participants' sociodemographic charac-

| Sample characteristics
Most of the institutions surveyed in this study have been operating in Bopa and Houéyogbé for more than 10 years ( Table 1) and 77% of them had organized nutrition learning sessions. NHCWs were predominantly women. At the village level, the majority of community leaders were over 40 years old, had five children or more and had been living in the community for more than 10 years. All the mothers surveyed were between 15 and 49 years old, and most of them were married and had fewer than five children. The Sahouè was the dominant ethnic group in both mothers' and community leaders' groups.
Moreover, 31% of mothers and 59% of leaders had received no formal instruction (Table 2).
We did not observe any differences in the perceptions of participants related to the order of presentation of the two communication media. Nor did participants' socioeconomic and demographic characteristics had any particular influence on their perceptions of the videos and posters. Thus, the presentation of our results does not take these parameters into account.

| Inventory of communication media used in nutrition sensitization programs
Among the institutions that organized nutrition awareness-raising sessions (n = 23 out of 30), five (5) did not use any communication media at all. The others (n = 18) mainly used, in descending order, image/picture boxes (n = 11), posters (n = 6), radio broadcasts and theaters (n = 2 for both), informational handouts, and cooking demonstrations (n = 1 for both); videos were seldom used (n = 1). Some institutions used more than one material.
In the villages, 48 out of 81 community leaders and mothers who participated in the FGDs had already benefited from nutritional advice, mainly from health centers. In 29 cases, these nutrition sessions incorporated no communication media. Picture boxes were used in 16 of the cases and posters in 3.

| Assessment of learning videos and posters
3.3.1 | Appeal and suitability for local communities Approximately 73% of the NHCWs found that videos were more suited to communicating with local/rural communities than posters.
Videos were seen as both an innovative medium and more attractive than posters.

| SWOT analysis
Videos offer major opportunities, including their attractiveness and the clarity of their messages (Table 3). Since the videos were in local languages, they could be self-utilized, even by people with little or no formal instruction. As videos do not require a facilitator's presence except for during a question-and-answer session after the projection, they represent a major advantage in terms of standardization of messages. On the other hand, videos offer limited time for imagination, reflection, and learning processes because of their temporality; they may therefore not be suitable for learning large amounts of messages. Video also requires non-negligible logistical features, including electricity and specific equipment; however, in settings where these amenities are not a problem, it can be used in both small and large groups. Posters offer the possibility to deliver a large amount of learning messages, but the clarity of messages and learning processes from participants very much rely on the facilitator's skills (speaking skills, interaction with participants, etc.) and on standardization across facilitators. Static images from posters are likely to facilitate memorization and can be displayed permanently so that participants can access the material at will. Since posters are more traditional and common than videos, they may be perceived as an overused medium and thus be associated with a lack of motivation and mobilization from the community.

| DISCUSS ION
This study which aimed at assessing the place of videos among the public speaking abilities and pedagogical skills could also be determinant. Thus, the opportunity to present standardized messages through videos seems to be key, particularly in contexts where both the facilitators and the audience are likely to have little or no formal instruction (Bentley et al., 2014;Gagliano, 1988). However, video sessions also demand more self-discipline from participants (Kay, 2012;Martinez, 2001;Sun & Rueda, 2012). In our study, mother faced many distractions during nutrition sessions and these are mostly linked to children. To address this problem, videos could be made available on demand so that women can watch them as many times as they want, can, and need to. Mobile phones could be a mean to access videos, as their use is now fairly widespread, even in rural communities (Chib et al., 2008;Khan et al., 2018). However, in our study area, smartphones and mobile phones capable of playing videos are usually owned by men and young males, not women; access to videos would therefore typically be at the household level.
Alternatively, providing smartphones to community leaders, especially leaders of women's associations, could be another way to organize video-based awareness-raising sessions at the community level.
This approach would allow exchanges and interactions with peers and offer opportunities for mothers to ask for further explanations after viewing the videos. Making learning videos widely available, that is, to all community members who have suitable devices, can create an environment conducive to behavior change for mothers (Glanz et al., 2008).
Despite their great potential, learning videos still need improvement since some messages could be misunderstood, due to the speed of images for example. In a review, Tuong et al. (2014) reported that videos as communication media can be effective in influencing some health behaviors and not effective for others. In addition, videos content needs to be adapted to rural realities in order to allow participants to identify with the characters in the scenes and conceptualize the information (Ramsay et al., 2012). Videos can be used to illustrate real practices and to visually highlight information that would be impossible to describe orally, in writing or with simple picture. On the other hand, when citing elements/components of the same set (e.g., foods from the same group), posters received a better appraisal. According to Régimbeau (1997) and Mayer et al. (2005), unlike moving pictures that impose their rhythm on the viewer, static images adapt to an individual's 'time' and allow him/her to learn at his/her own pace, hence favoring memorization. Therefore, the themes to be addressed during the nutrition sensitization sessions may determine the pertinence of videos or posters as the most appropriate communication medium.
Participants' enthusiasm for video can be great. Even if this is an opportunity for learning, this enthusiasm could be linked to the novelty of videos, and we cannot assume that this phenomenon will persist. Consequently, the use of videos should not be considered a panacea in awareness raising, and a mix of different media may be preferred. Videos are sometimes criticized for their distracting nature, which could obscure the messages to some extent. As shown in a study in India (Wadhwa & Sabharwal, 2018), people enjoyed the nutrition advice provided by videos, but few actually adopted the appropriate behaviors. In the same context in Benin, our research team (Bodjrenou et al., 2020) showed that learning videos were not more effective than posters in improving mothers' complementary feeding practices. Even if the attractiveness of videos is a major TA B L E 3 SWOT (strengths, weaknesses, opportunities, and threats) analysis of the use of videos and posters in nutrition sensitization in selected villages of the districts of Bopa and Houéyogbé. advantage, more needs to be done to enable participants to learn something beyond the entertainment aspect. The pedagogy of the educators remains a key element to support individuals in their learning.

| CON CLUS I ON AND IMPLI C ATI ON S FOR RE S E ARCH AND PR AC TI CE
The of small devices such as smartphones, at individual or small group levels, is suggested to counterbalance the lack of regular electricity and of appropriate equipment, and to promote their self-utilization.

ACK N OWLED G M ENTS
The authors would like to sincerely thank all the participants in the study and Mr. BESSAN Samson who participated in the data collection.

FU N D I N G I N FO R M ATI O N
This study was funded by the Ministry of Foreign Affairs of Finland and the Agriculture for Nutrition and Health CGIAR Research Program. The first author had also received a PhD allowance from IRD.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

E TH I C A L A PPROVA L
The authors declare that they do not have any conflict of interest.

MOTHERS
The investigation team, consisting of a moderator and a rapporteur, is welcomed by the village chief while two councilors hurry to gather the participants. Over the next few minutes, almost all of the mothers arrive with their babies on their backs or in their arms.
At 5:24 pm, the ten (10) mothers selected for the study are present under a shed in the village chief's courtyard, and the session can begin.
After the members of the team introduce themselves, they explain to the participants the reason for their presence, the different stages of the session, the instructions and rules of courtesy to be respected and the request for their consent to record the exchanges and take photos. Then, the moderator administers a characterization questionnaire to each mother, while the rapporteur sets up the logistics.
At 5:57 pm, the session starts. The poster on the theme 'dietary diversity' is shown to mothers. We observe some participants whispering among themselves; others seem to have come out of obligation and are therefore in a hurry to leave. They are asked to Next, the video on the same theme is shown. During the film we observe a noticeably high level of attention among the mothers, which was not the case during the exchanges regarding the poster -they are very captivated by the video. Unfortunately, at that moment, it seems some children (under 2 years old) are a little jealous of the attention the video is receiving. We witness the cries and demands of children, which distract the mothers. Some reprimand their children, asking them to be quiet. Unfortunately, some mothers are obliged to attend to their children, thus drawing their focus elsewhere; still, they try to watch the video from a distance.
Moreover, the video attracts the curiosity of the neighbors, who invited themselves early on to observe the session from around the shed. Some women whisper their displeasure at not having been selected to participate in the session. At the end of the video, the mothers ask for a replay. After the replay, the moderator asks the participants what they learned from the video and what they understood. Many concepts are retained, yet somewhat misunderstood or misinterpreted. The moderator then gives further explanations, which are followed by discussions with the mothers.
The nutrition sensitization session ends at 6:46 pm. With the help of a data collection guide, the moderator speaks with participants about their opinions on the poster and video presented, as well as their preference between the two communication media. They give many suggestions and ways to better adapt the content of the poster and the videos to their community. They also express a desire for the tools to be disseminated throughout their community as soon as possible. Another song is sung to close the session. The mothers thank the team for the valuable information and advice they provided and leave happy. Finally, the team puts away their materials and thanks the village chief and his councilors for their collaboration.
At 7:38 pm, the team says goodbye and leaves the village, very satisfied with the session.